International Jour nal of Applie d Rese arc h 2019; 5(4): 274-278

ISSN Print: 2394-7500 ISSN Online: 2394-5869 A comparative study on immediate effects of traction Impact Factor: 5.2 IJAR 2019; 5(4): 274-278 straight leg and bent leg raise on hamstring muscle www.allresearchjournal.com Received: 07-02-2019 flexibility in normal individuals Accepted: 09-03-2019

Pooja D Kapadia Intern at Late Shree Fakirbhai Pooja D Kapadia and Dr. Virendra K Meshram Pansare Education Foundation’s College Of Abstract Physiotherapy, Nigdi, Pune, Background: Muscular flexibility is an important aspect of normal human function. Limited flexibility Maharashtra, India has been shown to predispose a person to several musculoskeletal overuse injuries and significantly affect a person’s level of function. The objective of our study was to find out the effect of mulligan Dr. Virendra K Meshram Traction (TSLR) on hamstring flexibility, to find out the effect of Mulligan bent Leg Associate Professor, Raise (BLR) on hamstring flexibility & Comparison of Mulligan TSLR & Mulligan BLR on hamstring Department of Cardiovascular and Respiratory flexibility in normal individuals. Physiotherapy, Late Shree Method: For the present study, a total of 124 physiotherapy students were screened; of which 50 adults Fakirbhai Pansare education with hamstring muscle tightness were recruited and randomly divided into two groups: Group A- given Foundation’s College Of Mulligan Traction Straight Leg Raise and Group B- given Mulligan Bent Leg Raise. Hamstring Physiotherapy, Nigdi, Pune, flexibility was measured before and after the application of each stretching technique with the use of sit Maharashtra, India and reach test. Results: Paired t test showed significant improvement in hamstring muscle flexibility on pre-post values for Group A-Traction Straight Leg Raise (12.597 ± 2.842, 17.80 ± 3.060) at p<0.0001. Also, Wilcoxon Signed Rank Test showed significant improvement in hamstring muscle flexibility on pre- post values for Group B-Bent Leg Raise (12.152 ± 3.024, 15.423 ± 2.80) at p<0.0001. However, Traction Straight Leg Raise (5.203±1.518) was more significant than Bent Leg Raise (3.271±1.341) at p<0.0001 on the Mann Whitney Test.

Conclusion: Thus both Mulligan’s Traction Straight Leg Raise and Bent leg Raise are effective in

improving the hamstring muscle flexibility in normal individuals, but Mulligan’s traction straight leg raise technique was more effective in improving hamstring flexibility.

Keywords: Traction Straight Leg Raise, Bent Leg Raise, Hamstring muscle flexibility, Normal Individuals

Introduction Flexibility is defined as the ability of a muscle to lengthen, allowing one joint or more to

move through a (ROM), and is an essential component of normal [1, 2] biomechanical functioning . Muscle extensibility is an essential element of biomechanical function [3]. Limited muscle extensibility is a common problem that affects various patient populations as well as healthy able-bodied individuals [4, 5, 6]. The ability of an individual to move smoothly depends on his flexibility, an attribute that enhances both safety and optimal [7] physical activities . Flexibility is an important physiological component of physical fitness, and reduced flexibility can cause inefficiency in the workplace and is also a risk factor for low [7]. The posterior femoral muscles, biceps femoris, semitendinosus, and semimembranosus, are colloquially termed the ‘hamstrings. The flexibility of hamstring muscle is important for general and athletic population and of almost importance for health Correspondence Dr. Virendra K Meshram care professionals, to achieve this goal one needs to know the most effective and efficient [8] Associate Professor, technique to gain hamstring flexibility . Lack of hamstring muscles extensibility conditions Department of Cardiovascular a decrease of pelvic mobility [9]. This invariably leads to biomechanical changes in the and Respiratory pressure distribution of the spine and consequent spinal disorders [10]. Therefore, poor Physiotherapy, Late Shree hamstring extensibility has been associated with thoracic hyper kyphosis [11], spondylolysis Fakirbhai Pansare education [12] [13] [14] [15] Foundation’s College Of , disc herniation changes in lumbopelvic rhythm and . Hamstring Physiotherapy, Nigdi, Pune, tightness is also associated with low back and lower extremity musculoskeletal disorders Maharashtra, India leading to biomechanical changes of the pelvis and low back [16].

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Stretching techniques are the treatments used to improve moved passively through the range of SLR to the onset of muscular extensibility to improve ROM, and can help discomfort and then immediately returned to the resting prevent damage in daily life or sports, reduce muscle pain, position. Three repetitions of Mulligan’s Traction Straight and improve muscle capability. There are various treatment Leg Raise were done with 7 seconds hold and 5 seconds for the hamstring stretching like active release technique, relax time. The pain free Traction Straight Leg Raise was passive stretching, static stretching [17], PNF Stretching given for 3 repetitions. Techniques [18, 19], eccentric stretching exercises [20] for improving hamstring flexibility. Brian Mulligan has developed a most ingenious compilation of manual techniques. Unlike the other mobilization procedures, Mulligan performed while patients were moving, either actively or passively, or while they were performing a resisted muscle contraction [21]. Indications for use of Mulligan’s Traction Straight Leg Raise (TSLR) and Bent Leg Raise (BLR) techniques are limited range of motion of hip flexion together with low back pain with or without referred leg pain. The intention of this technique is to restore normal mobility. It stretches the lower extremity muscles in combination of hamstring, adductors and rotators. The Traction Straight Leg Raise and Bent Leg Raise techniques are painless interventions that are said to have immediate benefits [22]. Hence this study is designed to compare the

effectiveness of two forms of manual therapy interventions such as Traction Straight Leg Raise and Bent Leg Raise Fig 1: Traction Straight Leg Raise Technique

techniques on hamstring muscle flexibility. [25] Group B: Mulligan Bent Leg Raise Procedure Participant was in supine lying on a high couch with the The study was conducted in the duration of September 2018 investigator in walk stand position lateral to the leg, which till March 2019. Ethical approval was taken from the ethical was being stretched. Hip and Knee of the side to be committee. Total of 124 physiotherapy students were stretched was bent at 90˚- 90 ˚. Participant's flexed knee was screened for hamstring muscle tightness. Hamstring muscle placed over the shoulder, the popliteal fossa of the knee tightness was assessed using 90-90 hip and knee extension resting on the shoulder. A distraction (longitudinal traction test. Subjects were in a supine position. Passive flexion of force along the long axis of femur) was applied at the lower hip joint was done while the knee was fully extended to the end of femur and the participant was asked to push the end point where firm resistance was detected in the shoulder with his or her leg followed by voluntary hamstring muscle group. Any person whose contra lateral relaxation. The traction was maintained throughout the hip goes into flexion will be included for the intervention. technique. At this point of relaxation, the bent knee was Total of 50 students were selected based upon the inclusion pushed up as far as possible in the direction of the shoulder and exclusion criteria. Inclusion Criteria- 1.Physiotherapy on the same side in a pain free range. This stretch was students. 2. Age 18-25 years. 3. Hamstring muscle tightness sustained for 7 seconds and then 5 seconds of relaxation. If - 90-90 hip knee extension test positive. Exclusion Criteria- the pain or restriction eased, the hip was taken further in to 1.Any musculoskeletal pain or deformities of the lower flexion. It was ensured that there was no pain during the extremity. 2. Any neurological symptoms affecting the procedure; if it was painful the direction of the leg raise was lower limbs. 3. Subjects performing regular exercises or altered medially or laterally. The process was repeated 3 stretching. 4. Non willing population. Participants were times till the knee of the participant was beyond the informed about the aim, objective and method of the study. shoulder of therapist. The contra lateral leg was kept relaxed Samples were divided into 2 random groups via lottery and allowed to move as it goes. system- Group A and Group B. Pre-interventional readings for hamstring flexibility was taken using the sit and reach test. Group A (n=25) was given Mulligan’s Traction Straight Leg raise (TSLR) technique. Whereas, Group B (n=25) was given Mulligan’s Bent Leg Raise (BLR) technique. Immediate post-interventional readings for hamstring flexibility was taken using the sit and reach test. The data was then analyzed and results were obtained. Outcome Measure was Sit-and-reach (SR) test in which a fingertips-to-tangent feet distance is measured are probably the most widely used lineal measures of flexibility.

Group A: Mulligan Traction Straight Leg Raise [24] The subjects lay supine with their arms by their sides and a single pillow under the head. Sustained maximum traction force to the limb, applied in line with the long axis of the

leg, with the knee extended. The limb was simultaneously Fig 2: Mulligan’s Bent Leg Raise Technique

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Data analysis and results using Paired t test. (Table 1) Group B given Bent Leg Raise Statistical analyses were performed using the Graph Pad (n=25) statistical analysis of uneven distribution of data was INSTAT software. Total sample of 50 was divided into two done using the Wilcoxon Signed Rank Test. (Table 1) The groups. Group A -Traction Straight Leg Raise (n=25) comparison between data of Group A and Group B was statistical analysis of normally distributed data was done done using Mann- Whitney Test. (Table 2)

Table 1: Mean Values of Pre and Post Intervention of Group A (Traction Straight Leg Raise) and Group B (Bent Leg Raise)

Group A: Traction Straight Leg Raise Group B: Bent Leg Raise

Pre Intervention Mean 12.597 ± 2.842 12.152 ± 3.024 Post Intervention Mean 17.80 ± 3.060 15.423 ± 2.80 P Value <0.0001 (extremely significant) <0.0001 (extremely significant)

In the above table, it is seen that both traction straight leg raise and bent leg raise are statistically significant in improving the hamstring muscle flexibility.

Graph 1: Comparison between Pre and Post Intervention between Group A (Traction Straight Leg Raise) and Group B (Bent Leg Raise)

Graph 2: Comparison of Mean differences Between Pre- and Post- Intervention Values Of Group A(Mulligan’s Traction Straight Leg Raise) and Group B (Mulligan’s Bent Leg Raise)

Table 2: Mean values differences Between Pre- and Post- Intervention Values Of Group A (Mulligan’s Traction Straight Leg Raise) and Group B (Mulligan’s Bent Leg Raise)

Groups Mean Difference P Value Group A- Traction Straight Leg Raise 5.203±1.518 <0.0001 (extremely significant) Group B- Bent Leg Raise 3.271±1.341

In the above table, it is seen that when both the Groups are Discussion compared for improvement in hamstring muscle flexibility, The purpose of present study was designed to compare the Group A- Traction straight leg raise is statistically more immediate effects of Mulligan’s Traction Straight Leg Raise significant than Group B- bent leg raise. and Bent Leg Raise on hamstring flexibility in normal

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individuals. When the hamstring flexibility values using the in pre and posttest measures when observed within groups sit and reach test were compared in between the GROUP A [31]. One of the beneficial effect of the BLR technique might – Traction Straight Leg Raise, it was found that there was be a change in stretch tolerance of the hamstrings. This significant statistical improvement (p<0.0001) in the increase in hamstring muscle flexibility obtained by Bent hamstring flexibility in post-interventional values (17.80 ± Leg Raise also relates with the findings of Vijay and 3.060) from pre-interventional values (12.597 ± 2.842).The Ratnam who studied the immediate effect of active release increase in straight leg raise range in Traction Straight Leg technique vs. Mulligan Bent Leg Raise in subjects with Raise group may be due to the fact that during Traction hamstring tightness: a randomized clinical trial. Result of Straight Leg Raise stretch, various receptors exert an the study demonstrated that ART and Mulligan BLR inhibitory influence on lower limb alpha-motor neuron increases immediate post intervention hamstring flexibility activity. Golgi tendon organs around the knee, hip and spine and range of motion. Both the groups showed improvement probably initiate various segmental reflex pathways during in popliteal angle and sit and reach flexibility measurements traction of the limb. Likewise, Golgi tendon organs are [32]. Study done to compare the effectiveness of Mulligan’s activated during large amplitude stretching movements such straight leg raise traction and bent leg raise on hamstring as SLR. This processing of information in the nervous flexibility suggested possible mechanism for pain relief can system may inhibit the activity of the muscles being be due to static stretching that increases flexibility of lengthened during SLR by dampening the afferent activity muscles. In the current study, when the mean difference of type II muscle spindles or by decreasing motor neuron between pre-and post- interventional values of hamstring excitability via 1-b fibers. Hence, improvement in range of flexibility was compared between both the groups, it was SLR may be directly related to inhibition of the hamstring found that Group A- Traction Straight Leg Raise muscles rather than changes due to stretch tolerance [26]. In (5.203±1.518) was statistically more significant in straight leg raise static stretching with traction was given in improving hamstring flexibility than Group B- Bent Leg which the muscle is slowly elongated to tolerance and the Raise (3.271±1.341), with the p value<0.0001. This result position held with the muscle in its greatest tolerated length can be supported by the study done by Pratishtha K. & [27]. Traction has shown to improve painfully restricted Jagga V. in which the TSLR group the EMG activity straight leg raise in previous studies [28]. Also a recent study, decreased by 22.52%, thus suggesting improved muscle found that straight leg raise traction technique significantly performance as decrease in muscle activity shows that improved the SLR angle with similar explanation for the muscle is able to do the same work with less recruitment of cause of improvement of range [29]. A study done by Roopa motor units thus rendering it more efficient, while in the Desai on “Carryover effect of Mulligan Traction straight leg BLR group the EMG activity increased by 14.64%. raise in individuals with hamstring tightness” which concluded that a single intervention of Mulligan Traction Conclusion straight leg raise technique was effective in improving The study concludes that both Mulligan’s Traction Straight Active knee extension angle and Sit and Reach extensibility Leg Raise and Bent leg Raise have immediate effects in and also that it has shown improvements in sustaining and improving the hamstring muscle flexibility in normal maintaining the increased ROM and hamstring extensibility individuals, but when both the techniques were compared, it even after 24 hours in normal individuals also supports our was found that Mulligan’s traction straight leg raise findings for improvement of hamstring flexibility by technique was more effective in improving hamstring Traction Straight Leg raise [30]. Also in the current study, flexibility. when the hamstring flexibility values using the sit and reach test were compared in between the GROUP B – Bent Leg References Raise, it was found that there was significant statistical 1. Zachezewski JE. Improving flexibility. In: Scully RM, improvement (p<0.0001) in the hamstring flexibility in post- Barnes MR, eds. Physical Therapy. Philadelphia, PA: interventional values (15.423 ± 2.80) from pre- JB Lippincott, 1989, 698-9. interventional values (12.152 ± 3.024). “Brian Mulligan” 2. Hopper D, Deacon S, Das S, Jain A, Riddell D, Hall T has advocated the use of bent leg raise for stretching et al. Dynamic soft tissue mobilisation increases hamstring to improve flexibility by increasing the range of hamstring flexibility in healthy male subjects. Br J motion. This intervention consists of contract relax cycles Sports Med. 2005; 39:594-8. applied to hamstrings that provide peripheral somatic input 3. Odunaiya NA, Hamzat TK, Ajayi OF. 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